MEDICARE: PEDIATRIC OPHTHALMOLOGY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WP0200X	Pediatric Optometrist	003979	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225278880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC OPHTHALMOLOGY PC

Provider Business Mailing Address
First Line	:	5050 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3707
Country	:	US
Telephone Number	:	616-957-0866
Fax Number	:	616-957-4102

Provider Business Practice Location Address
First Line	:	5050 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3707
Country	:	US
Telephone Number	:	616-957-0866
Fax Number	:	616-957-4102

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. DEBORAH M DROSTE
Credential	:	RN BSN
Telephone Number	:	616-957-0866

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	09/11/2025

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